MEDICARE: CARDINAL CARE PHARMACY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336L0003X	Long Term Care Pharmacy
4	3336C0003X	Community/Retail Pharmacy	2018014920	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2177556	OTHER		PK

General Provider Information

NPI Number	:	1477042554
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARDINAL CARE PHARMACY INC

Provider Business Mailing Address
First Line	:	2319 WELDON PKWY
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-3207
Country	:	US
Telephone Number	:	800-984-4432
Fax Number	:	314-552-7297

Provider Business Practice Location Address
First Line	:	2319 WELDON PKWY
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-3207
Country	:	US
Telephone Number	:	800-984-4432
Fax Number	:	314-552-7297

Authorized Official
Title or Position	:	OWNER
Name	:	JOAO DA SILVA
Credential	:
Telephone Number	:	800-984-4432

Provider Enumeration Date	:	05/04/2018
Last Update Date	:	07/19/2018

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